Ambetter from Superior HealthPlan provides quality healthcare solutions that help residents of Wisconsin live better. With a variety of affordable coverage options, they make it easier to stay healthy.
Plan Name Essential Care 1 (2016) – Standard Essential Care 5 (2016) with 3 Free PCP Visits – Standard
Medical Deductible (Ind/Fam) $6,800/$13,600 $6,800/$13,600
Prescription Drug Deductible (Ind/Fam) Integrated with medical ded. Integrated with medical ded.
Out-of-pocket Maximum (Ind/Fam) $6,800/$13,600 $6,800/$13,600
Annual Well Visit/ Preventive Care No charge No charge
PCP Office Visit No charge after ded. No charge after ded.
Specialist Office Visit No charge after ded. No charge after ded.
Imaging (CT/PET Scans, MRIs) No charge after ded. No charge after ded.
X-rays & Diagnostic Imaging No charge after ded. No charge after ded.
Urgent Care No charge after ded. No charge after ded.
Emergency Room* No charge after ded. No charge after ded.
Emergency Transportation* No charge after ded. No charge after ded.
Inpatient Facility Fee No charge after ded. No charge after ded.
Inpatient Hospital Physician & Surgical Services No charge after ded. No charge after ded.
Outpatient Facility Fee No charge after ded. No charge after ded.
Outpatient Surgery Physician/Surgical Services No charge after ded. No charge after ded.
Labs & Diagnostics No charge after ded. No charge after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services No charge after ded. No charge after ded.
Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) No charge after ded. No charge after ded.
Skilled Nursing Facility No charge after ded. No charge after ded.
Pediatric Vision- Routine Eye Exam (1 visit per year) 100% Covered 100% Covered
Pediatric Vision- Eyeglasses (frames, 1 per year) 100% Covered 100% Covered
Pedicatric Vision- Lenses (per pair) 100% Covered 100% Covered
Pharmacy*
(Generic / Preferred / Non-preferred / Specialty)
$20 / No charge after ded. / No charge after ded. / No charge after ded. No charge after ded. / No charge after ded. / No charge after ded.
/ No charge after ded.
Plan Name Balanced Care 1 (2016) – Standard Balanced Care 2 (2016) – Standard Balanced Care 10 (2016) – Standard
Medical Deductible (Ind/Fam) $5,500/$11,000 $6,500/$13,000 $4,500/$9,000
Prescription Drug Deductible (Ind/Fam) Integrated with medical ded. Integrated with medical ded. Integrated with medical ded.
Out-of-pocket Maximum (Ind/Fam) $6,500/$13,000 $6,500/$13,000 $6,500/$13,000
Annual Well Visit/ Preventive Care No charge No charge No charge
PCP Office Visit 30 30 20
Specialist Office Visit 60 60 40
Imaging (CT/PET Scans, MRIs) 20% after ded. No charge after ded. 20% after ded.
X-rays & Diagnostic Imaging 20% after ded. No charge after ded. 20% after ded.
Urgent Care 100 100 100
Emergency Room* 20% after ded. No charge after ded. 20% after ded.
Emergency Transportation* 20% after ded. No charge after ded. 20% after ded.
Inpatient Facility Fee 20% after ded. No charge after ded. 20% after ded.
Inpatient Hospital Physician & Surgical Services 20% after ded. No charge after ded. 20% after ded.
Outpatient Facility Fee 20% after ded. No charge after ded. 20% after ded.
Outpatient Surgery Physician/Surgical Services 20% after ded. No charge after ded. 20% after ded.
Labs & Diagnostics 20% after ded. No charge after ded. 20% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services 30 30 20
Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) 20% after ded. No charge after ded. 20% after ded.
Skilled Nursing Facility 20% after ded. No charge after ded. 20% after ded.
Pediatric Vision- Routine Eye Exam (1 visit per year) 100% Covered 100% Covered 100% Covered
Pediatric Vision- Eyeglasses (frames, 1 per year) 100% Covered 100% Covered 100% Covered
Pedicatric Vision- Lenses (per pair) 100% Covered 100% Covered 100% Covered
Pharmacy*
(Generic / Preferred / Non-preferred / Specialty)
$10 / $50 / 20% after Rx ded. / 20% after Rx ded. $15 / $50 / No charge after ded. / No charge after ded. $10 / $50 / 20% after ded. / 20% after ded.
Plan Name Secure Care 1 (2016) with 3 Free PCP Visits – Standard
Medical Deductible (Ind/Fam) $1,000/$2,000
Prescription Drug Deductible (Ind/Fam) $500/$1,000
Out-of-pocket Maximum (Ind/Fam) $6,350/$12,700
Annual Well Visit/ Preventive Care No charge
PCP Office Visit 20% after ded.
Specialist Office Visit 20% after ded.
Imaging (CT/PET Scans, MRIs) 20% after ded.
X-rays & Diagnostic Imaging 20% after ded.
Urgent Care 20% after ded.
Emergency Room* $250 after ded.
Emergency Transportation* 20% after ded.
Inpatient Facility Fee 20% after ded.
Inpatient Hospital Physician & Surgical Services 20% after ded.
Outpatient Facility Fee 20% after ded.
Outpatient Surgery Physician/Surgical Services 20% after ded.
Labs & Diagnostics 20% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services 20% after ded.
Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) 20% after ded.
Skilled Nursing Facility 20% after ded.
Pediatric Vision- Routine Eye Exam (1 visit per year) 100% Covered
Pediatric Vision- Eyeglasses (frames, 1 per year) 100% covered
Pedicatric Vision- Lenses (per pair) 100% covered
Pharmacy*
(Generic / Preferred / Non-preferred / Specialty)
$10 / $25 after Rx ded. / $75 after Rx ded. / 30% after Rx ded.
When you begin shopping for a Marketplace health plan, you’ll see plan options with different metal tiers such as Gold, Silver and Bronze plans. But the only difference between these plans is how much premium you’ll pay each month and how much you’ll pay for certain medical services. A Bronze plan typically gives you lower monthly premium payments, but potentially higher out-of-pocket costs – if you end up needing a lot of care. And a Gold plan may have higher monthly premiums, but that helps you limit your out-of-pocket costs later. If you’re looking for a balance on your monthly premium payments and your out-of-pocket costs, Silver plans provide just that. And, Silver plans are the only plans with additional out-of-pocket payment reductions (cost sharing reductions)! This helps lower the costs of your copays, deductibles and coinsurance. So, if you are eligible for a subsidy and cost sharing, Silver plans offer the highest value.
Ambetter Wisconsin Coverage Map

Plan Brochures
Plan Name Deductible Out-Of-Pocket Coinsurance Brochures Summary of Benefits
Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Limited Cost Share) $1,000 $6,350 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (Limited Cost Share) $5,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (Limited Cost Share) $6,500 $6,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (Limited Cost Share) $4,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) (Limited Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Limited Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (Limited Cost Share) $5,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (Limited Cost Share) $6,500 $6,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (Limited Cost Share) $4,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) + Vision (Limited Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Limited Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Standard Cost Share) $1,000 $6,350 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (Standard Cost Share) $5,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (Standard Cost Share) $6,500 $6,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (Standard Cost Share) $4,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) (Standard Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Standard Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (Standard Cost Share) $5,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (Standard Cost Share) $6,500 $6,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (Standard Cost Share) $4,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) + Vision (Standard Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Standard Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (73% AV Cost Share) $3,500 $5,000 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (73% AV Cost Share) $4,500 $4,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (73% AV Cost Share) $4,000 $5,000 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (73% AV Cost Share) $3,500 $5,000 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (73% AV Cost Share) $4,500 $4,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (73% AV Cost Share) $4,000 $5,000 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (87% AV Cost Share) $350 $2,250 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (87% AV Cost Share) $1,750 $1,750 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (87% AV Cost Share) $1,000 $1,750 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (87% AV Cost Share) $350 $2,250 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (87% AV Cost Share) $1,750 $1,750 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (87% AV Cost Share) $1,000 $1,750 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (94% AV Cost Share) $0 $650 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (94% AV Cost Share) $550 $550 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (94% AV Cost Share) $250 $550 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (94% AV Cost Share) $0 $650 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (94% AV Cost Share) $550 $550 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (94% AV Cost Share) $250 $550 20% Coinsurance View PDF View PDF
Contact Us
Phone: (312) 726-6565
Email: [email protected]

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